Patient Encounter Form

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The Lam Institute for Hair Restoration
Samuel. M. Lam, M.D.
Patient Encounter Form
Name: Last _______________
First: ___________ M.I.______ Date__/__/__
Street Address: _______________________________________ Apt #________
City: ____________________
State: _________Zip: _______ D.O.B. __/__/__
Sex __M __F SS # ______-___-______
Email: ______________________
Phone _____________(h)
______________ (w)
_____________ (cell)
Occupation _______________
Age _____
Preferred way of contact_______
How did you hear about us?__________________________________________
Emergency Contact ______________________Phone#__________________
Primary Care Physician’s phone #__________________________________
Pharmacy phone#_____________________fax#_______________________
What is your primary interest(s) in coming here? (Check all that apply)
□ Slow hair loss
□ Maintain hair count
□ Restore hair
□ Other __________
How long have you been concerned about your hair loss?
□ Less than 1 year
□ 1-5 years
□ 5 years and more
What type of hair loss solution(s) have you tried? (Check all that apply)
□ Propecia
□ Rogaine
□ Hair transplant
□ Hairpiece
□ Laser
What surgeries have you had in the past and when (including hair transplant)?
________________________________________________________________
What other medical problems do you have? ___________________________________
Are you taking any medication? (Please list) ___________________________________
Do you have any medication allergies? ______________________________________
Explain your allergic reaction: ______________________________________________
Federal Law requires us to obtain a valid Driver’s License or
current Photo ID for your records. Please provide a copy with
your consultation form.

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